Treatment with opioid antagonists and mTOR inhibitors

ABSTRACT

Embodiments of the invention provide methods of treating a disorder or disease characterized by cellular proliferation and migration by co-administering a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No. 12/933,784, filed on Oct. 14, 2010, now U.S. Pat. No. 8,685,995, which is a national stage filing under 35 U.S.C. 371 of International Application No. PCT/US2009/037825, filed on Mar. 20, 2009, which claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Application No. 61/038,577, filed on Mar. 21, 2008, the complete disclosures of which are incorporated herein by reference in their entireties.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

Not applicable.

INTRODUCTION

Cell growth and proliferation are normal ongoing processes in all living organisms, involving numerous factors and signals that are delicately balanced to maintain regular cell cycles. Whether or not mammalian cells will grow and divide is determined by a variety of feedback control mechanisms, such as the availability of space in which a cell can grow, and the secretion of specific stimulatory and inhibitory factors in the immediate environment.

mTOR is a large polypeptide serine/threonine kinase of the phosphatidylinositol 3-kinase (PI3K)-related kinase (PIKK) family. mTOR lies downstream from the PI3K pathway, and functions as an intermediary in a variety of cell signalling events to regulate cell growth and proliferation. mTOR activity is regulated by the serine/threonine kinase Akt, and recent evidence indicates that these kinases interact through a complex feedback inhibition pathway. mTOR modulates cell replication by controlling translation of key proteins that are required for progression of the cell cycle through the G1 to the S phase. That is, mTOR controls the translation of specific mRNAs via regulation of the phosphorylation state of several proteins involved in the translation of mRNA, mainly 4E-PB1, P7056K and eEFZ.

The mTOR pathway, with its PI3K and Akt constituents, is a critical regulator of the proliferation of cells that responds to nutrients, hormones and growth factors, such as VEGF. Growth factors can activate PI3K signaling by binding to cognate cell surface receptors, thereby initiating a signaling cascade through Akt that results in the activation of mTOR. Recent studies have demonstrated that mTOR inhibitors have antiproliferative and antiangiogenic effects by inhibiting both growth factor-mediated signaling and growth factor translation.

In cancer cells, multiple dysregulation mechanisms within the PI3K pathway upstream of mTOR have been documented as causing increased mTOR activity, and consequently, increasing tumor growth. Thus, dysregulation of the mTOR signaling pathway has been implicated in the progression of cancer, and inhibitors of mTOR are currently being investigated as cancer therapeutic agents. mTOR inhibitors are also potent immunosuppressive agents. One such agent, sirolimus, is currently being used for the prophylaxis of organ rejection. Other mTOR inhibitors that are currently marketed or under development include temsirolimus (Torisel™; Wyeth), RAD001 (everolimus; Novartis), MK-8669 (deforolimus; Merck & Ariad pharma), FK506 (tacrolimus; Astellas), TOP216 (Toptarget A/S), OSI-027 (OSI Pharma), TAFA93 (Isotechnika), and nab-rapamycin (APP Pharma). Many of these mTOR inhibitors are rapamycin or rapamycin derivatives.

In addition to their development as organ transplant rejection prophylaxis and anti-cancer agents, mTOR inhibitors are also being developed for the treatment of rheumatoid arthritis, autoimmune disorders, psoriasis, multiple sclerosis, Parkinson's disease, stroke and peripheral neuropathies. For example, the mTOR inhibitor rapamycin has been shown to have efficacy in several animal models of autoimmunity such as experimental allergic encephalomyelitis, insulin-dependent diabetes mellitus, murine lupus and adjuvant arthritis, and has been proposed as a potential therapy in rheumatoid diseases. As to the latter, antibodies from individuals with rheumatoid or Graves' disease activate fibroblasts through the mTOR pathway, which can be inhibited with rapamycin, suggesting that an mTOR blockade would be of value in limiting inflammation in these diseases. Rapamycin was also found to reduce collagen mRNA levels in human fibroblasts, suggesting that mTOR positively regulates collagen type I synthesis. Thus, mTOR blockade may also be of benefit in fibrotic diseases such as scleroderma, where fibrotic lesions disrupt normal tissue architecture and contribute to organ failure. Protein expression of the CCR5 chemokine receptor utilized by HIV-1 to enter CD4 T cells and macrophages is also inhibited by rapamycin, suggesting a clinical utility for blockade of CCR5-mediated viral entry in immune cells. Recently, rapamycin treatment was shown to significantly reduce clinical disease in a patient with dermatomyositis, an autoimmune condition that affects muscle and skin. mTOR inhibitors also have potent neuroprotective and neuroregenerative properties in culture and animal models.

However, several adverse reactions have been observed with mTOR inhibitors in clinical studies. These include rash, asthenia, mucositis, anorexia, peripheral edema, hypertriglyceridemia, hypertension, hypercholesterolemia, hypercreatinemia, constipation, abdominal pain, diarrhea, headache, fever, urinary tract infection, anemia, nausea, arthralgia, pain, and thrombocytopenia. At least a subset of these adverse reactions appear to be dose dependent.

BRIEF DESCRIPTION

Methods and pharmaceutical combinations embodying the principles of embodiments of the invention include co-administering mTOR inhibitors with a class of compounds generally described as μ-opioid receptor antagonists. The inventors have found that a μ-opioid receptor antagonist, such as methylnaltrexone, can be co-administered with mTOR inhibitors in a synergistic manner that permits reducing the therapeutically effective dosing of the mTOR inhibitors. As noted above, at least a subset of the adverse reactions that are associated with mTOR inhibitors appear to be dose-dependent, and thus, the co-administration of a μ-opioid receptor antagonist allows for the use of decreased doses of these mTOR inhibitors and the concommitant reduction in the incidence and/or severity of adverse reactions. The inventors have demonstrated that methylnaltrexone inhibits the activation of the kinase Akt, which is an upstream event in the activation of mTOR. Akt and mTOR are involved in a complex regulatory feedback loop, and simultaneous targeting of both Akt and mTOR in accordance with embodiments of the invention has a synergistic effect.

The use of μ-opioid receptor antagonists in combination with mTOR inhibitors may greatly increase the anticancer and immunosuppressive efficacy of these inhibitors and allow for their use at lower doses, thus lessening the occurrence/severity of adverse effects. Moreover, use of μ-opioid receptor antagonists, such as methylnaltrexone, to increase the efficacy of these mTOR inhibitors with a resultant decrease in dosing required for a therapeutic effect would also greatly decrease the high cost of treatment associated with mTOR inhibitors. A method of improving the therapeutic index or utility of an mTOR inhibitor by co-administering a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist is further contemplated.

Methods embodying the principles of embodiments of the invention include attenuating, e.g., inhibiting or reducing, cell proliferation and migration, particularly endothelial cell proliferation and migration, using a combination of mTOR inhibitors and μ-opioid receptor antagonists, including, but not limited to, those that are peripherally-restricted antagonists. According to an aspect of the invention, a method of treatment is provided that includes administering to a subject with a disorder characterized by unwanted migration and/or proliferation of cells, a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. The treatment may inhibit one or both of migration and proliferation, and the cells may suitably be endothelial cells, and of particular interest, vascular endothelial cells. Thus, in another embodiment, this disorder characterized by unwanted migration or proliferation of vascular endothelial cells is unwanted angiogenesis. In other words, a method of treating unwanted angiogenesis is contemplated.

According to another aspect, methods of attenuating migration and/or proliferation of cells of a tumor or cancer are provided, including contacting the cells with an antimigratory or antiproliferative amount of an mTOR inhibitor and a μ-opioid receptor antagonist. In attenuating abnormal cell proliferation, activation of the mTOR/Akt signaling pathway is inhibited in a mammal by administering to the mammal a synergistic therapeutically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. Thus, in accordance with an embodiment of the invention, a method of inhibiting mTOR/Akt pathway signaling in cells, e.g., endothelial cells, is also provided, which method includes contacting the cells with a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. Another embodiment of the invention further includes a method of treating cancerous tissue in a subject including, administering to the subject an amount of an mTOR inhibitor and a μ-opioid receptor antagonist sufficient to inhibit mTOR/Akt pathway-mediated effects in the cancerous tissue, as well as a method including contacting a tissue or a population of cells with a composition or combination including an amount of at least one of an mTOR inhibitor and at least one of a μ-opioid receptor antagonist under conditions effective to synergistically inhibit mTOR/Akt pathway-induced cell proliferation and migration.

In a further aspect, a method of treating a disorder or disease characterized by hyperproliferation of cells is provided, which method includes co-administering to a subject suffering thereof, a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. Yet another embodiment of the invention includes a method of treating cancer, e.g., a method of inhibiting growth of a tumor in a subject in need thereof, which method includes co-administering a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist.

A further embodiment of the invention provides a method of treating abnormal proliferation of cells expressing a growth factor receptor in a mammal by administering to the mammal a synergistic therapeutically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. In particular embodiments, the growth factor receptor is vascular endothelial growth factor receptor (VEGF-R), epidermal growth factor receptor (EGF-R) or insulin-like growth factor receptor (IGF-R). Thus, in accordance with other embodiments of the invention, a method of inhibiting growth factor signaling in endothelial cells is also provided. In specific embodiments, the growth factor is VEGF, EGF or IGF.

By administering the synergistic combination of mTOR inhibitors and μ-opioid antagonists, in accordance with embodiments of the invention, methods of treatment of autoimmune diseases, psoriasis, neurodegenerative diseases, CCRS-mediated viral entry into immune cells, and nausea and emesis are also contemplated.

Pharmaceutical combinations and packages of mTOR inhibitors and μ-opioid receptor antagonists as well as accompanying instructions for co-administration are also provided in accordance with embodiments of the invention.

mTOR inhibitors for use in the methods in accordance with embodiments of the invention generally include compounds that inhibit cell replication by blocking progression of the cell cycle from G1 to S by inhibiting phosphorylation of serine 389 of p70S6 kinase by mTOR. Known mTOR inhibitors include rapamycin and rapamycin derivatives. Several other small molecule inhibitors of mTOR activity have also been identified. Use of more than one mTOR inhibitor in the combination therapy in accordance with embodiments of the inventions is also contemplated.

In some embodiments, the μ-opioid receptor antagonist may be a peripheral μ-opioid receptor antagonist. Peripherally-restricted μ-opioid receptor antagonists are generally heterocyclic amine compounds that also belong to several different classes of compounds. For example, one class is quaternary derivatives of morphinan, and in particular, quaternary derivatives of noroxymorphone. In one embodiment, the quaternary derivative of noroxymorphone is suitably, e.g., N-methylnaltrexone (or simply methylnaltrexone), N-methylnaloxone, N-methylnalorphine, N-diallylnormorphine, N-allyllevallorphan, or N-methylnalmefene. Another class of peripherally-restricted antagonists is N-substituted piperidines. In one embodiment, the N-piperidine is a piperidine-N-alkylcarbonylate, such as alvimopan. Other classes of compounds that may be of value in embodiments of the invention are quaternary derivatives of benzomorphans, quaternary derivatives of normorphanin and polymer conjugates of tertiary derivatives of morphanin, benzomorphan and normorphanin.

Embodiments of the invention also encompass administration of more than one μ-opioid receptor antagonist in therapeutic combinations. Antagonist combinations may include combinations of μ-antagonists and combinations of μ- and κ-antagonists, for example, a combination of methylnaltrexone and alvimopan, or a combination of naloxone and methylnaltrexone.

Other μ-opioid receptor antagonists that may be of use in the methods in accordance with embodiments of the invention may include tertiary derivatives of morphinan, and in particular, tertiary derivatives of noroxymorphone which include, e.g., naloxone.

BRIEF DESCRIPTION OF THE DRAWINGS

Embodiments of the invention may be better understood and appreciated by reference to the detailed description presented herein in conjunction with the accompanying drawings of which:

FIG. 1 depicts the chemical structures of naltrexone and methylnaltrexone, and the conversion reaction of naltrexone to methylnaltrexone;

FIG. 2 is an immunoblot demonstrating VEGF-induced phosphorylation (activation) of Akt at serine⁴⁷³ and threonine³⁰⁸ using anti-phospho-serine⁴⁷³-Akt, anti-phospho-threonine³⁰⁸-Akt and anti-Akt specific antibodies in human endothelial cells in the presence of bevacizumab, 5-FU, methylnaltrexone, a combination of bevacizumab and methylnaltrexone and a combination of 5-FU and methylnaltrexone;

FIG. 3 is a graph depicting dose-related effects of inhibition of VEGF-induced phosphorylation of Akt at serine⁴⁷³ (A) and threonine³⁰⁸ (B) by methylnaltrexone;

FIG. 4 is a graph depicting dose-related effects on inhibition of VEGF-induced endothelial cell proliferation by rapamycin;

FIG. 5 is a graph depicting dose-related effects on inhibition of VEGF-induced endothelial cell migration by rapamycin;

FIG. 6 is a graph depicting synergistic inhibition of VEGF-induced endothelial cell proliferation with a combination of methylnaltrexone and rapamycin;

FIG. 7 is a graph depicting synergistic inhibition of VEGF-induced endothelial cell migration with a combination of methylnaltrexone and rapamycin.

FIG. 8 is an immunoblot demonstrating the effect of methylnaltrexone and temsirolimus on VEGF-induced phosphorylation (activation) of Akt at serine⁴⁷³ and threonine³⁰⁸ using anti-phospho-serine⁴⁷³-Akt, anti-phospho-threonine³⁰⁸-Akt and anti-Akt specific antibodies in human endothelial cells.

FIG. 9 shows immunoblots demonstrating (A) the effect of methylnaltrexone and temsirolimus on the VEGF-induced formation of mTOR Complex 1 and mTOR Complex 2 and (B) the effect of PI3 kinase inhibition, Src depletion and Rictor depletion on VEGF-induced phosphorylation (activation) of Akt at serine⁴⁷³ and threonine³⁰⁸ using anti-phospho-serine⁴⁷³-Akt, anti-phospho-threonine³⁰⁸-Akt and anti-Akt specific antibodies in human endothelial cells.

FIG. 10 provides graphs depicting (A) synergistic inhibition of VEGF-induced endothelial cell proliferation with a combination of methylnaltrexone and temsirolimus and (B) synergistic inhibition of VEGF-induced endothelial cell migration with a combination of methylnaltrexone and temsirolimus.

FIG. 11 provides graphs demonstrating that the synergistic inhibition of endothelial cell (A) proliferation and (B) migration with a combination of methylnaltrexone and temsirolimus is regulated by tyrosine phosphatase activity.

FIG. 12 is a schematic representation of a molecular basis of the synergistic activity of methylnaltrexone and mTOR inhibitors.

DETAILED DESCRIPTION

According to the principles manifest in embodiments of the invention, pharmaceutical combinations and methods are provided utilizing a combination of mTOR inhibitors and μ-opioid receptor antagonists. Methods in accordance with embodiments of the invention include treating a disorder characterized by unwanted and undesired cell proliferation and migration, particularly unwanted and undesired endothelial cell proliferation and/or migration, by co-administering an mTOR inhibitor and a μ-opioid receptor antagonist. As explained in the Examples below, combinations of an mTOR inhibitor and a μ-opioid receptor antagonist, such as methylnaltrexone (MNTX), provide an unexpected synergy in reducing unwanted cell proliferation and migration, e.g., VEGF-induced proliferation and migration of endothelial cells.

Before explaining at least one embodiment of the invention, it is to be understood that the invention is not limited in its application to the details set forth in the following description and as exemplified by the Examples. Such description and Examples are not intended to limit the scope of the invention as set forth in the appended claims. The invention is capable of other embodiments or of being practiced or carried out in various ways. While the following detailed description and Examples describe the invention through reference to embodiments utilizing rapamycin, temsirolimus and methylnaltrexone as suitable drugs, it should be understood that other mTOR inhibitors and μ-opioid receptor antagonists may also be suitable for use in accordance with the principles of the invention.

Further, no admission is made that any reference, including any patent or patent document, cited in this specification constitutes prior art. In particular, it will be understood that, unless otherwise stated, reference to any document herein does not constitute an admission that any of these documents form part of the common general knowledge in the art in the United States or in any other country. Any discussion of the references states what their authors assert, and the applicant reserves the right to challenge the accuracy and pertinency of any of the documents cited herein.

Throughout this disclosure, various aspects of this invention may be presented in a range format. It should be understood that the description in range format is merely for convenience and brevity, and should not be construed as an inflexible limitation on the scope of the invention. Accordingly, as will be understood by one skilled in the art, for any and all purposes, particularly in terms of providing a written description, all ranges disclosed herein also encompass any and all possible subranges and combinations of subranges thereof, as well as all integral and fractional numerical values within that range. As an example, a range of 20% to 40% can be broken down into ranges of 20% to 32.5% and 32.5% to 40%, 20% to 27.5% and 27.5% to 40%, etc., all of which are understood to be expressly enumerated in this specification. Any listed range can be easily recognized as sufficiently describing and enabling the same range being broken down into at least equal halves, thirds, quarters, fifths, tenths, etc. As a non-limiting example, each range discussed herein can be readily broken down into a lower third, middle third, and upper third, etc.

As will also be understood by one skilled in the art, all language such as “up to,” “at least,” “greater than,” “less than,” “more than” and the like include the number recited and refer to ranges which can be subsequently broken down into subranges as discussed above. In the same manner, all ratios disclosed herein also include all subratios falling within the broader ratio. These are only examples of what is specifically intended. Further, the phrases “ranging/ranges between” a first indicate number and a second indicate number and “ranging/ranges from” a first indicate number “to” a second indicate number are used herein interchangeably.

Further, the use of “comprising,” “including,” “having,” and variations thereof herein is meant to encompass the items listed thereafter and equivalents thereof as well as additional items, e.g., other steps and/or ingredients. These terms encompass the terms “consisting of” and “consisting essentially of.” The use of “consisting essentially of” means that the composition or method may include additional ingredients and/or steps, but only if the additional ingredients and/or steps do not materially alter the basic and novel characteristics of the claimed composition or method.

Unless otherwise defined, all scientific and technical terms are used herein according to conventional usage and have the same meaning as commonly understood by one of ordinary skill in the art to which the invention belongs. However, as used herein, the following definitions may be useful in aiding the skilled practitioner in understanding the invention:

“Subject” refers to mammals, e.g., humans, mice, dogs, cats, rats.

“Alkyl” refers to a univalent aliphatic hydrocarbon group which is saturated and which may be straight, branched, or cyclic having from 1 to about 10 carbon atoms in the chain, and all combinations and subcombinations of chains therein. Exemplary alkyl groups include, but are not limited to, methyl, ethyl, n-propyl, isopropyl, butyl, isobutyl, sec-butyl, tert-butyl, pentyl, cyclopropyl, cyclobutyl, cyclopentyl, and cyclohexyl.

“Lower alkyl” refers to an alkyl group having 1 to about 6 carbon atoms.

“Alkenyl” refers to a univalent aliphatic hydrocarbon group containing at least one carbon-carbon double bond and having from 2 to about 10 carbon atoms in the chain, and all combinations and subcombinations of chains therein. Exemplary alkenyl groups include, but are not limited to, vinyl, propenyl, butynyl, pentenyl, hexenyl, and heptnyl.

“Alkynyl” refers to a univalent aliphatic hydrocarbon group containing at least one carbon-carbon triple bond and having from 2 to about 10 carbon atoms in the chain, and combinations and subcombinations of chains therein. Exemplary alkynyl groups include, but are not limited to, ethynyl, propynyl, butynyl, pentynyl, hexynyl, and heptynyl.

“Alkylene” refers to a divalent aliphatic hydrocarbon group having from 1 to about 6 carbon atoms, and all combinations and subcombinations of chains therein. The alkylene group may be straight, branched, or cyclic. There may be optionally inserted along the alkylene group one or more oxygen, sulfur, or optionally substituted nitrogen atoms, wherein the nitrogen substituent is an alkyl group as described previously.

“Alkenylene” refers to a divalent alkylene group containing at least one carbon-carbon double bond, which may be straight, branched, or cyclic. Exemplary alkenylene groups include, but are not limited to, ethenylene (—CH═CH—) and propenylene (—CH═CHCH₂—).

“Cycloalkyl” refers to a saturated monocyclic or bicyclic hydrocarbon ring having from about 3 to about 10 carbons, and all combinations and subcombinations of rings therein. The cycloalkyl group may be optionally substituted with one or more cycloalkyl-group substituents. Exemplary cycloalkyl groups include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and cycloheptyl.

“Acyl” means an alkyl-CO group wherein alkyl is as previously described. Exemplary acyl groups include, but are not limited to, acetyl, propanoyl, 2-methylpropanoyl, butanoyl, and palmitoyl.

“Aryl” refers to an aromatic carbocyclic radical containing from about 6 to about 10 carbons, and all combinations and subcombinations of rings therein. The aryl group may be optionally substituted with one or two or more aryl group substituents. Exemplary aryl groups include, but are not limited to, phenyl and naphthyl.

“Aryl-substituted alkyl” refers to a linear alkyl group, preferably a lower alkyl group, substituted at a terminal carbon with an optionally substituted aryl group, preferably an optionally substituted phenyl ring. Exemplary aryl-substituted alkyl groups include, for example, phenylmethyl, phenylethyl, and 3(4-methylphenyl)propyl.

“Heterocyclic” refers to a monocyclic or multicyclic ring system carbocyclic radical containing from about 4 to about 10 members, and all combinations and subcombinations of rings therein, wherein one or more of the members of the ring is an element other than carbon, for example, nitrogen, oxygen, or sulfur. The heterocyclic group may be aromatic or nonaromatic. Exemplary heterocyclic groups include, for example, pyrrole and piperidine groups.

“Halo” refers to fluoro, chloro, bromo, or iodo.

“Co-administration” or “co-administering” is meant to refer to a combination therapy in which two or more agents are administered to a patient or subject by any administration route. Co-administration of agents may also be referred to as combination therapy or combination treatment. The agents may be in the same dosage formulation or separate formulations. For combination treatment with more than one active agent, where the active agents are in separate dosage formulations, the active agents can be administered concurrently, or they each can be administered at separately staggered times. The agents of a combination treatment may be administered simultaneously or sequentially (e.g., one agent may directly follow administration of the other or the agents may be given episodically, e.g., one can be given at one time followed by the other at a later time, e.g., within a week), as long as they are given in a manner sufficient to allow both agents to achieve effective concentrations in the body. The agents may also be administered by different routes, e.g., one agent may be administered intravenously while a second agent is administered intramuscularly, intravenously, or orally.

The terms “peripheral,” or “peripherally-restricted” or “peripherally-acting” in reference to μ-opioid receptor antagonists, designate μ-opioid receptor antagonists that act primarily on physiological systems and components external to the central nervous system. In other words, they exhibit reduced or substantially no central nervous system (CNS) activity. For example, they do not readily cross the blood-brain barrier in an amount effective to inhibit the central effects of opioids, i.e., they do not effectively inhibit the analgesic effects of opioids when administered peripherally, that is, they do not reduce the analgesic effect of the opioids. The peripheral μ-opioid receptor antagonist compounds employed in the embodiments of the invention suitably exhibit less than about 5-15% of their pharmacological activity in the CNS, with about 0% (i.e., no) CNS activity, being most suitable. The non-centrally acting characteristic of a peripheral μ-opioid receptor antagonist is often related to charge, polarity, and/or size of the molecule or species. For example, peripherally-acting quaternary amine μ-opioid receptor antagonists as described herein are positively charged while the central-acting tertiary amine μ-opioid receptor antagonists are neutral molecules.

As used herein, the term “mTOR inhibitor” means a compound or ligand, or a pharmaceutically acceptable salt thereof, which inhibits cell replication by blocking the progression of the cell cycle from G1 to S by modulating mTOR activity or expression. The term includes the neutral tricyclic compound rapamycin (sirolimus) and other rapamycin compounds, including, e.g., rapamycin derivatives, rapamycin analogues, and other macrolide compounds as well as other structurally distinct small molecules, e.g. fused bicyclic compounds, that inhibit mTOR activity. These include compounds with a structural similarity to rapamycin, e.g., compounds with a similar macrocyclic structure that have been modified to enhance therapeutic benefit. mTOR inhibitors, including rapamycin derivatives, are described hereinafter.

The terms “treating” or “treatment” used herein include any means of control of a medical or pathological condition such as prevention, care, relief of the condition, attenuation, alleviation, a reduction of the condition or symptoms of the condition, and inhibition or arrest of progression of the condition.

As used herein, the term “side effect” is meant to refer to an effect other than the purpose or desired effect of a drug. Side effects may be beneficial or undesirable, i.e., adverse. In the instant case, undesirable effects often occur after the administration of an mTOR inhibitor. Such side effects include rash, asthenia, mucositis, anorexia, peripheral edema, hypertriglyceridemia, hypertension, hypercholesterolemia, increased creatinine, constipation, abdominal pain, diarrhea, headache, fever, urinary tract infection, anemia, nausea, arthralgia, pain, and thrombocytopenia.

The term “solvate” refers to a compound provided herein or a salt thereof, which further includes a stoichiometric or non-stoichiometric amount of solvent bound by non-covalent intermolecular forces. Where the solvent is water, the solvate is a hydrate.

As used herein, the term “potency” refers to the ability or capacity of an anticancer agent to treat cancer in a subject suffering from cancer. Potency may also be expressed as the dose of a drug required to produce a specific effect of a given intensity.

In certain embodiments, the term “unwanted” in connection with cell proliferation and migration, e.g., “unwanted proliferation” or “unwanted migration,” is meant to refer to “abnormal or pathological or dysregulated or undesirable or inappropriate” proliferation, division, growth or migration of cells that is not part of normal cell turnover, metabolism, growth or propagation, and generally is occurring more rapidly or to a significantly greater extent than typically occurs in a normally functioning cell of the same type and does not serve normal function. Unwanted proliferation and unwanted migration is manifest in disorders that are hyperproliferative in nature and include, but are not limited to, cancers, such as melanoma, lung cancer, breast cancer, pancreatic cancer, prostate cancer, colon cancer or ovarian cancer, psoriasis, rheumatoid arthritis, epidermolytic by perkeratosis, restratosis, restenosis, endometriosis and abnormal wound healing.

In describing an optically active compound, the prefixes R and S are used to denote the absolute configuration of the molecule about its chiral center(s). The symbols (+) and (−) are used to denote the optical rotation of the compound, i.e., the direction in which a plane of polarized light is rotated by the optically active compound. The (−) prefix indicates that the compound is levorotatory, that is, the compound rotates the plane of polarized light to the left or counterclockwise. The (+) prefix indicates that the compound is dextrorotatory, that is, the compound rotates the plane of polarized light to the right or clockwise. However, the sign of optical rotation, (+) and (−), is not related to the absolute configuration of the molecule, R and S.

In the following description of the methods of the invention, process steps are carried out at room temperature and atmospheric pressure unless otherwise specified.

In one aspect, an embodiment of the invention relates to methods of attenuating abnormal or undesirable cellular processes, for example, unwanted cell migration and/or proliferation, particularly unwanted endothelial cell migration and/or proliferation. Methods include administering one or more mTOR inhibitors and one or more μ-opioid receptor antagonists in a synergistically effective amount to cells of, e.g., a tissue or an organ of a patient or subject, particularly endothelial cells of a tissue or organ of a patient, to inhibit cell migration and/or proliferation, e.g., endothelial cell migration and/or proliferation.

μ-opioid receptor antagonists have been shown to inhibit unwanted proliferation and migration induced by opioids, endogenous or exogenous, and growth factors, such as VEGF, PDGF, S1P etc. Peripheral μ-opioid receptor antagonists, in particular, have shown a substantial efficacy in inhibiting opioid and growth factor-induced proliferation and migration of endothelial cells as disclosed in co-pending U.S. patent application Ser. No. 11/908,058. The peripheral μ-opioid receptor antagonist methylnaltrexone (MNTX) inhibits both opioid and growth factor-induced proliferation and migration in a concentration dependent manner. Furthermore, it has now been discovered that μ-opioid receptor antagonists, and the peripheral μ-opioid receptor antagonist MNTX in particular, inhibit agonist-induced endothelial cell (EC) proliferation and migration via inhibition of Akt. The agonists can be opioids, exogenous and/or endogenous, angiogenic factors (e.g., VEGF), and other proliferation and/or migration stimulating factors (e.g., PDGF, S1P, S1P₃ receptor, RhoA, etc).

μ-opioid receptor antagonists have also been shown to inhibit the ability of viruses to infect target cells. Peripheral μ-opioid receptor antagonists, in particular, have shown a substantial efficacy in inhibiting the viral entry of HIV and the expression of CCR5, the cell surface receptor of this virus, as disclosed in the co-pending U.S. patent application Ser. No. 10/163,482 incorporated herein by reference.

Embodiments of the invention demonstrate that μ-opioid receptor antagonists co-administered with mTOR inhibitors give rise to a significantly enhanced antiproliferative effect on cancerous cells, and thus provide an increased therapeutic effect, e.g., administering peripheral μ-opioid receptor antagonists to certain tumors can potentiate tumor response to mTOR inhibitors. As illustrated in the Examples below, a significantly increased antiproliferative and antimigratory effect is obtained with the above disclosed co-administered combinations utilizing lower concentrations of the mTOR inhibitor and the μ-opioid receptor antagonist compared to the treatment regimes in which the drugs are used alone. For example, co-administration of a μ-opioid receptor antagonist with an mTOR inhibitor in accordance with embodiments of the invention may reduce the dose of the mTOR inhibitor or increase potency or efficacy or both. Further, the co-administration of a μ-opioid receptor antagonist and an mTOR inhibitor in accordance with embodiments of the invention may also have prophylactic value.

There is also the potential to provide therapy wherein adverse side effects associated with mTOR inhibitors are considerably reduced compared to those normally observed with the mTOR inhibitors used alone in larger doses. These side effects include rash, asthenia, mucositis, anorexia, peripheral edema, hypertriglyceridemia, hypertension, hypercholesterolemia, increased creatinine, constipation, abdominal pain, diarrhea, headache, fever, urinary tract infection, anemia, nausea, arthralgia, pain, and thrombocytopenia. At least a subset of these adverse reactions are dose dependent. The potential for lower dosing is achieved utilizing embodiments in accordance with the invention.

There is the further potential to provide therapy wherein the high costs associated with mTOR inhibitor therapy are considerably reduced compared to those normally observed with the mTOR inhibitors used alone in larger doses. In addition, the co-administration of a μ-opioid receptor antagonist with an mTOR inhibitor can considerably increase the efficacy and potency of the mTOR inhibitor compared to that normally observed with the mTOR alone.

Methods embodying the principles manifest in embodiments of the invention include attenuating, e.g., inhibiting or reducing, unwanted cell proliferation and migration, particularly endothelial cell proliferation and migration, using mTOR inhibitors and μ-opioid receptor antagonists, including, but not limited to, those that are peripherally-restricted antagonists. According to one aspect of the invention, a method of treatment is provided that involves administering to a subject with a disorder characterized by unwanted migration or proliferation of endothelial cells, a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. The treatment may inhibit one or both of migration and proliferation. In a further embodiment, the unwanted migration or proliferation is unwanted migration or proliferation of vascular endothelial cells that is treated with a synergistic amount of an mTOR inhibitor and a μ-opioid receptor antagonist. In another embodiment, the disorder characterized by unwanted migration or proliferation of vascular endothelial cells is unwanted angiogenesis. Thus, a method of treating unwanted angiogenesis is contemplated.

According to yet another aspect, methods of attenuating migration and/or proliferation of cells of a tumor or cancer are provided, which methods include contacting the cells with an antimigratory or antiproliferative amount of mTOR inhibitor and a μ-opioid receptor antagonist. In attenuating cell proliferation, a method of treating abnormal cell proliferation of cells that exhibit increased activation of the mTOR/Akt signaling pathway in a mammal is provided, which method includes administering to the mammal a synergistic therapeutically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. Thus, a method of inhibiting mTOR/Akt pathway signaling in endothelial cells is also provided. Methods involve contacting the cells with a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. A method of treating cancerous tissue in a subject is also provided, which method includes administering to the subject an amount of an mTOR inhibitor and a μ-opioid receptor antagonist sufficient to inhibit mTOR/Akt pathway-mediated effects in the cancerous tissue, as well as a method including contacting a tissue or a population of cells with a composition or combination including an amount of at least one of an mTOR inhibitor and at least one of a μ-opioid receptor antagonist under conditions effective to inhibit mTOR/Akt pathway-induced proliferation and migration.

In yet another embodiment, a method of treating abnormal proliferation of cells that express a growth factor receptor in a mammal is provided, which method includes administering to the mammal a synergistic therapeutically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. In particular embodiments, the growth factor receptor is vascular endothelial growth factor receptor (VEGF-R), epidermal growth factor receptor (EGF-R) or insulin-like growth factor receptor (IGF-R). Thus, a method of inhibiting growth factor signaling in endothelial cells is also provided. In specific embodiments, the growth factor is VEGF, EGF or IGF. Methods involve contacting the cells with a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. A method of treating cancerous tissue in a subject is also provided, which method includes administering to the subject an amount of an mTOR inhibitor and a μ-opioid receptor antagonist sufficient to inhibit growth factor-induced effects in the cancerous tissue, as well as a method including contacting a tissue or a population of endothelial cells with a composition or combination including an amount of at least one of an mTOR inhibitor and at least one of a μ-opioid receptor antagonist under conditions effective to inhibit growth factor-induced proliferation and migration. It is particularly contemplated that these effects in cancerous tissue are VEGF-, EGF- or IGF-induced.

In yet a further embodiment, a method of treating abnormal cell proliferation of cells that express a hormone receptor in a mammal is provided, which method includes administering to the mammal a synergistic therapeutically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. In particular embodiments, the hormone receptor is estrogen receptor (ER), progesterone receptor (PR) or androgen receptor (AR). Thus, a method of inhibiting hormone signaling in endothelial cells is also provided. In specific embodiments, the hormone is estrogen, progesterone or androgen. Methods involve contacting the cells with a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. A method of treating cancerous tissue in a subject is also provided, which method includes administering to the subject an amount of an mTOR inhibitor and a μ-opioid receptor antagonist sufficient to inhibit hormone-induced effects in the cancerous tissue, as well as a method including contacting a tissue or a population of endothelial cells with a composition or combination including an amount of at least one of an mTOR inhibitor and at least one of a μ-opioid receptor antagonist under conditions effective to inhibit hormone-induced proliferation and migration. It is particularly contemplated that these effects in cancerous tissue are estrogen-, progesterone- or androgen-induced.

In yet a further aspect, a method of treating a disorder or disease characterized by hyperproliferation of cells is provided, which method includes co-administering to a subject suffering thereof a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. Yet another embodiment of the invention is a method of treating cancer in a subject in need thereof, comprising co-administering a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. A further embodiment of the invention is a method of inhibiting growth of a tumor in a subject in need thereof, comprising co-administering a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist.

In a further aspect, a method of treating an autoimmune disease in a patient is provided, which method includes co-administering a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. Autoimmune diseases of the invention include, but are not limited to, allergic encephalomyelitis, insulin-dependent diabetes mellitus, lupus, rheumatoid arthritis, multiple sclerosis, dermatomyositis, Grave's disease and adjuvant arthritis.

Yet another aspect of the invention provides a method of treating psoriasis in a patient, including co-administering a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. In a particular embodiment, the synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist is applied topically.

A further embodiment of the invention is a method of treating a neurodegenerative disease, which method includes the co-administration of a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. In particular embodiments, the neurodegenerative disease is Parkinson's disease or multiple sclerosis.

Yet a further embodiment of the invention is a method of inhibiting CCR5-mediated viral entry into immune cells which includes the co-administration of a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist. The inhibition of CCR5-mediated HIV entry into immune cells is particularly contemplated. Further, a method of treating HIV/AIDS which includes co-administering to a subject suffering thereof a synergistically effective amount of an mTOR inhibitor and a μ-opioid receptor antagonist is provided.

In another aspect, nausea and emesis, induced by treatment of cancer with mTOR inhibitor, may be alleviated by co-administering a μ-opioid receptor antagonist, such as the peripheral μ-opioid receptor antagonist methylnaltrexone.

As noted above, mTOR inhibitors include compounds or ligands, or pharmaceutically acceptable salts thereof, which inhibit cell replication by blocking the progression of the cell cycle from G1 to S through the modulation of mTOR activity or expression. mTOR inhibitors that are currently available or under development, include temsirolimus (Torisel™; Wyeth), RAD001 (everolimus; Novartis), MK-8669 (deforolimus; Merck & Ariad pharma), TOP216 (Toptarget A/S), OSI-027 (OSI Pharma), TAFA93 (Isotechnika), nab-rapamycin (APP Phama) and tacrolimus (FK506; Astellas).

mTOR inhibitors include rapamycin and related compounds. Rapamycin is a macrolide produced by Streptomyces. Rapamycins are potent immunosuppressive agents and are used clinically to prevent rejection of transplanted organs. Rapamycin and related compounds are also currently under development as anti-cancer therapuetic agents. The rapamycins useful in embodiments of the invention include compounds that are chemically or biologically modified as derivatives of the rapamycin nucleus, while still retaining immunosuppressive or anti-cancer properties. Accordingly, rapamycins include rapamycin itself, and esters, ethers, carbamates, oximes, hydrazones, and hydroxylamines of rapamycin, as well as rapamycins in which functional groups on the rapamycin nucleus have been modified, for example through reduction or oxidation.

Specifically, the structure of rapamycin is given as formula (A) shown below:

Many of the rapamycin derivatives disclosed above in current use or development have the basic rapamycin structure with substitutions at the C-40 position. If the substituent at position 40 is designated as R, then the following substitutions and corresponding compounds are: R=—OP(O)(Me)₂, AP23573 (International Patent Publication Nos. WO 98/02441 and WO 2001/14387); R=—OC(O)C(CH₃)(CH₂OH), temsirolimus (U.S. Pat. No. 5,362,718); R=—OCH₂CH₂OH, everolimus (U.S. Pat. No. 5,665,772); R=—OCH₂CH₂OEt, biolimus; R=-tetrazole, ABT-578 (International Patent Publication No. WO 99/15530). All patents and applications are hereby incorporated by reference.

Many other rapamycin derivatives include substitutions in the C-40 and/or C-16 and/or C-32 positions. Esters and ethers of rapamycin are described in the following patents, which are all hereby incorporated by reference: alkyl esters (U.S. Pat. No. 4,316,885); aminoalkyl esters (U.S. Pat. No. 4,650,803); fluorinated esters (U.S. Pat. No. 5,100,883); amide esters (U.S. Pat. No. 5,118,677); carbamate esters (U.S. Pat. Nos. 5,118,678; 5,411,967; 5,434,260; 5,480,988; 5,480,989; 5,489,680); silyl esters (U.S. Pat. No. 5,120,842); aminodiesters (U.S. Pat. No. 5,162,333); sulfonate and sulfate esters (U.S. Pat. No. 5,177,203); esters (U.S. Pat. No. 5,221,670); alkoxyesters (U.S. Pat. No. 5,233,036); O-aryl, -alkyl, -alkenyl, and -alkynyl ethers (U.S. Pat. No. 5,258,389); carbonate esters (U.S. Pat. No. 5,260,300); arylcarbonyl and alkoxycarbonyl carbamates (U.S. Pat. No. 5,262,423); carbamates (U.S. Pat. No. 5,302,584); hydroxyesters (U.S. Pat. No. 5,362,718); hindered esters (U.S. Pat. No. 5,385,908); heterocyclic esters (U.S. Pat. No. 5,385,909); gem-disubstituted esters (U.S. Pat. No. 5,385,910); amino alkanoic esters (U.S. Pat. No. 5,389,639); phosphorylcarbamate esters (U.S. Pat. No. 5,391,730); amidino carbamate esters (U.S. Pat. No. 5,463,048); hindered N-oxide esters (U.S. Pat. No. 5,491,231); biotin esters (U.S. Pat. No. 5,504,091); O-alkyl ethers (U.S. Pat. No. 5,665,772); and PEG esters of rapamycin (U.S. Pat. No. 5,780,462); 32-esters and ethers (U.S. Pat. No. 5,256,790). The preparation of these esters and ethers is disclosed in the patents listed above. All patents and applications are hereby incorporated by reference.

Also included are oximes, hydrazones, and hydroxylamines of rapamycin as disclosed in U.S. Pat. Nos. 5,373,014, 5,378,836, 5,023,264, and 5,563,145. The preparation of these oximes, hydrazones, and hydroxylamines is disclosed in the above-listed patents. The preparation of 40-oxorapamycin is disclosed in U.S. Pat. No. 5,023,263. All these patents are hereby incorporated by reference.

Other small molecule inhibitors of mTOR include fused bicyclic compounds (International Patent Publication Nos. WO 2007/61737, WO 2007/87395 and WO 2007/64993), heteroaromatic amines (International Patent Publication No. WO 2001/19828), pyrrolopyrimidine compounds (International Patent Publication No. WO 2005/47289), diphenyl-dihydro-indol-2-one derivatives (International Patent Publication No. WO 2005/97107), and trimethyl-dodeca-triene derivatives (US Patent Publication No. 2007/037887). All of these patents are hereby incorporated by reference.

The μ-opioid receptor antagonists in accordance with embodiments of the invention may include both centrally and peripherally acting μ-opioid receptor antagonists. However, it is contemplated that those antagonists of particular value are suitably the peripherally-restricted μ-opioid receptor antagonists.

μ-opioid receptor antagonists form a class of compounds that can vary in structure while maintaining their antagonist properties. These compounds include tertiary and quaternary morphinans, in particular noroxymorphone derivatives, N-substituted piperidines, and in particular, piperidine-N-alkylcarboxylates, and tertiary and quaternary benzomorphans, and tertiary and quaternary normorphinan derivatives, in particular 6-corboxy-normorphinan derivatives. Tertiary compound antagonists are fairly lipid soluble and cross the blood-brain barrier easily. Examples of μ-opioid receptor antagonists that cross the blood-brain barrier and are centrally (and peripherally) active include, e.g., naloxone (which is commercially available from Baxter Pharmaceutical Products, Inc.), and nalmefene (available, e.g., from DuPont Pharma). Peripherally-restricted antagonists, on the other hand, are typically charged, polar, and/or of high molecular weight, each of which impedes their crossing the blood-brain barrier. Methylnaltrexone is a quaternary derivative of the tertiary μ-opioid receptor antagonist, naltrexone. Addition of the methyl group to naltrexone forms a compound with greater polarity and lower lipid solubility. Thus, methylnaltrexone does not cross the blood-brain barrier and has the potential for blocking the undesired adverse effects which are typically mediated by peripherally located receptors.

A peripheral μ-opioid receptor antagonist for use in embodiments of the invention may be a compound which is a quaternary morphinan derivative, and in particular, a quaternary noroxymorphone of formula (I):

a single enantiomer, a mixture of enantiomers, an individual diastereomer, or a mixture of diastereomers thereof; or a pharmaceutically acceptable salt, solvate, or prodrug thereof, wherein R is alkyl, alkenyl, alkynyl, aryl, cycloalkyl-substituted alkyl, or arylsubstituted alkyl, and X⁻ is an anion, especially a chloride, bromide, iodide, carbonate or methylsulfate anion. The noroxymorphone derivatives of formula (I) can be prepared, for example, according to the procedure in U.S. Pat. No. 4,176,186, which is incorporated herein by reference; see also, U.S. Pat. Nos. 4,719,215; 4,861,781; 5,102,887; 5,972,954; and 6,274,591; U.S. Patent Application Nos. 2002/0028825 and 2003/0022909; and PCT publication Nos. WO 99/22737 and WO 98/25613, all of which are hereby incorporated by reference.

A compound of formula (I) of particular value is N-methylnaltrexone (or simply methylnaltrexone), wherein R is cyclopropylmethyl as represented in formula (II):

a single enantiomer, a mixture of enantiomers, an individual diastereomer, or a mixture of diastereomers thereof; or a pharmaceutically acceptable salt, solvate, or prodrug thereof, wherein X⁻ is as described above. Methylnaltrexone is a quaternary derivative of the μ-opioid receptor antagonist naltrexone. Methylnaltrexone exists as a salt (e.g., N-methylnaltrexone bromide) and the terms “methylnaltrexone” or “MNTX”, as used herein, therefore embrace such salts. “Methylnaltrexone” or “MNTX” thus specifically includes, but is not limited to, bromide salts, chloride salts, iodide salts, carbonate salts, and methylsulfate salts of methylnaltrexone. Names used for the bromide salt of MNTX in the literature, for example, include: methylnaltrexone bromide; N-methylnaltrexone bromide; naltrexone methobromide; naltrexone methyl bromide; SC-37359; MRZ-2663-BR; and N-cyclopropylmethylnoroxy-morphine-methobromide. Thus, herein, the term “methylnaltrexone” should be understood to mean any appropriate form of methylnaltrexone, e.g., N-methylnaltrexone or any pharmaceutically acceptable salt thereof, any prodrug thereof, enantiomers thereof, epimers thereof (the latter of which are described hereinafter).

The compounds of formulas (I) and (II), e.g., methylnaltrexone, may have chiral centers and can, therefore, occur as stereochemical isomers by virtue of the substituent placement on those chiral centers. Such stereochemical isomers, e.g., enantiomers, diastereomers, are within the scope of the compounds contemplated for use in embodiments of the invention. In the compositions and methods of embodiments of the invention, compounds employed may be individual stereoisomers, as well as mixtures of stereoisomers, e.g., mixtures of enantiomers, mixtures of diastereomers. In certain aspects, methods are provided that utilize compounds which are substantially pure stereoisomers. All tautomers are also intended to be encompassed within the compositions of the invention.

For example, the R and S configurations of methynaltrexone are known, and in some embodiments, isolated R—N isomers of methylnaltrexone may be utilized in formulations and methods. As used herein, the designation of “R—N-isomer” of methylnaltrexone refers to such compounds in the (R) configuration with respect to the nitrogen. Isolated isomer compounds include, but are not limited to, R—N isomer methylnaltrexone compounds described in U.S. patent application Ser. No. 11/441,395, and Patent Cooperation Treaty published application WO2006/127899, incorporated herein by reference. In some embodiments, the active compound is an R—N isomer methylnaltrexone, or a salt thereof. The R—N isomer of methylnaltrexone, described in U.S. Ser. No. 11/441,395, is an opioid antagonist.

In some embodiments, isolated S—N isomers of methylnaltrexone may be utilized in formulations and methods. As used herein, the designation of “S—N-isomer”of methylnaltrexone refers to such compounds in the (S) configuration with respect to the nitrogen. Isolated isomer compounds include, but are not limited to, S—N isomer of methylnaltrexone compounds described in U.S. patent application Ser. No. 11/441,452, and Patent Cooperation Treaty published application WO2006/127898, incorporated herein by reference. In some embodiments, the active compound is an S—N isomer methylnaltrexone, or a salt thereof. The S—N isomer of methylnaltrexone, described in U.S. Ser. No. 11/441,452, is an opioid agonist.

In certain embodiments, the methylnaltrexone utilized in formulations or dosage preparations described herein is a mixture of stereoisomers characterized in that it has an overall opioid antagonistic effect. For example, the methylnaltrexone may be a mixture of R—N and S—N methylnaltrexone such that a mixture itself acts as an antagonist and would be useful for methods of use described herein for opioid antagonists. In certain embodiments, R—N methylnaltrexone is used which is substantially free of S—N methylnaltrexone.

In certain embodiments of the invention, at least about 99.6%, 99.7%, 99.8%, 99.85%, 99.9%, or 99.95% of methylnaltrexone is in the (R) configuration with respect to nitrogen. Methods for determining the amount of (R)—N-isomer, present in a sample as compared to the amount of (S)—N-isomer present in that same sample, are described in detail in WO2006/127899, the entirety of which is hereby incorporated herein by reference. In other embodiments, methylnaltrexone contains 0.15%, 0.10%, or less (S)—N-isomer.

It will be understood by those skilled in the art that, where reference is made herein to amounts of methylnaltrexone utilized in formulations, dosage preparations, or methods, those amounts may refer to total amount of methylnaltrexone (or salt thereof), or to amount of relevant active form of methylnaltrexone for a particular purpose (e.g., opioid antagonism), whether or not other forms of methylnaltrexone are also present. Furthermore, as indicated herein, dosages or amounts are sometimes defined with reference to a particular form of methylnaltrexone (e.g., N-methylnaltrexone bromide). Where a different form or salt of methylnaltrexone is used, those of ordinary skill in the art will appreciate that such dosages or amounts may be adjusted to a dose or amount that provides an equivalent amount of active methylnaltrexone.

Methylnaltrexone is commercially available from, e.g., Mallinckrodt Pharmaceuticals, St. Louis, Mo. Methylnaltrexone is provided as a white crystalline powder, freely soluble in water, typically as the bromide salt. The compound as provided is 99.4% pure by reverse phase HPLC, and contains less than 0.011% unquaternized naltrexone by the same method. Methylnaltrexone can be prepared as a sterile solution at a concentration of, e.g., about 5 mg/mL.

Other peripheral μ-opioid receptor antagonists may include N-substituted piperidines, and in particular, piperidine-N-alkylcarboxylates as represented by formula (III):

wherein R¹ is hydrogen or alkyl; R² is hydrogen, alkyl, or alkenyl; R³ is hydrogen, alkyl, alkenyl, aryl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl-substituted alkyl, or aryl-substituted alkyl; R⁴ is hydrogen, alkyl, or alkenyl; A is OR⁵ or NR⁶R⁷; wherein R⁵ is hydrogen, alkyl, alkenyl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl-substituted alkyl, or aryl-substituted alkyl; R⁶ is hydrogen or alkyl; R⁷ is hydrogen, alkyl, alkenyl, aryl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl-substituted alkyl or aryl-substituted alkyl, or alkylene-substituted B or together with the nitrogen atom to which they are attached, R⁶ and R⁷ form a heterocyclic ring selected from pyrrole and piperidine; B is

wherein R⁸ is hydrogen or alkyl; R⁹ is hydrogen, alkyl, alkenyl, aryl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl-substituted alkyl or aryl-substituted alkyl or together with the nitrogen atom to which they are attached, R⁸ and R⁹ form a heterocyclic ring selected from pyrrole and piperidine; W is OR¹⁰, NR¹¹R¹², or OE; wherein R¹⁹ is hydrogen, alkyl, alkenyl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl-substituted alkenyl, or aryl-substituted alkyl; R¹¹ is hydrogen or alkyl; R¹² is hydrogen, alkyl, alkenyl, aryl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl-substituted alkyl, aryl-substituted alkyl, or alkylene-substituted C(═O)Y or, together with the nitrogen atom to which they are attached, R¹¹ and R¹² form a heterocyclic ring selected from pyrrole and piperidine; E is

alkylene-substituted (C═O)D, or —R¹³OC(═O)R¹⁴; wherein R¹³ is alkyl-substituted alkylene; R¹⁴ is alkyl; D is OR¹⁵ or NR¹⁶R¹⁷; wherein R¹⁵ is hydrogen, alkyl, alkenyl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl substituted alkyl, or aryl-substituted alkyl; R¹⁶ is hydrogen, alkyl, alkenyl, aryl, aryl-substituted alkyl, cycloalkyl, cycloalkenyl, cycloalkyl substituted alkyl, or cycloalkenyl-substituted alkyl; R¹⁷ is hydrogen or alkyl or, together with the nitrogen atom to which they are attached, R¹⁶ and R¹⁷ form a heterocyclic ring selected from the group consisting of pyrrole or piperidine;

Y is OR¹⁸ or NR¹⁹R²⁰; wherein R¹⁸ is hydrogen, alkyl, alkenyl, cycloalkyl, cycloalkenyl, cycloalkyl-substituted alkyl, cycloalkenyl-substituted alkyl, or aryl-substituted alkyl; R¹⁹ is hydrogen or alkyl; R²⁰ is hydrogen, alkyl, alkenyl, aryl, cycloalkyl, cycloalkenyl, cycloalkylsubstituted alkyl, cycloalkenyl-substituted alkyl, or aryl-substituted alkyl or, together with the nitrogen atom to which they are attached, R¹⁹ and R²⁰ form a heterocyclic ring selected from pyrrole and piperidine; R²¹ is hydrogen or alkyl; and n is 0 to 4.

Particular piperidine-N-alkylcarbonylates which may be of value are N-alkylamino-3,4,4 substituted piperidines, such as alvimopan represented below as formula (IV):

N-substituted piperidines may be prepared as disclosed in U.S. Pat. Nos. 5,270,328; 6,451,806; 6,469,030, all of which are hereby incorporated by reference. Alvimopan is available from Adolor Corp., Exton, Pa. Such compounds have moderately high molecular weights, a zwitterion form, and a polarity that prevent penetration of the blood-brain barrier.

Still other peripheral μ-opioid receptor antagonist compounds may include quaternary benzomorphan compounds. Quaternary benzomorphan compounds, which may be employed in embodiments of the invention, have the following formula (V):

wherein R¹ is hydrogen, acyl, or acetoxy; and R² is alkyl or alkenyl; R is alkyl, alkenyl, or alkynyl and X⁻ is an anion, especially a chloride, bromide, iodide, or methylsulfate anion.

Specific quaternary derivatives of benzomorphan compounds that may be employed in embodiments of the invention include the following compounds of formula (V): 2′-hydroxy-5,9-dimethyl-2,2-diallyl-6,7-benzomorphanium-bromide; 2′-hydroxy-5,9-dimethyl-2-n-propyl-2-allyl-6,7-benzomorphanium-bromide; 2′-hydroxy-5,9-dimethyl-2-n-propyl-2-propargyl-6,7-benzomorphanium-bromide; and 2′-acetoxy-5,9-dimethyl-2-n-propyl-2-allyl-6,7-benzomorphanium-bromide.

Other quaternary benzomorphan compounds that may be employed in embodiments of the invention are described, for example, in U.S. Pat. No. 3,723,440, the entire disclosure of which is incorporated herein by reference.

Other peripheral opioid antagonists may include 6-carboxy-normorphinan derivatives, particularly N-methyl-C-normorphinan derivatives, as described in U.S. Pat. No. 7,501,434, entitled “6-Carboxy-Normorphinan Derivatives, Synthesis and Uses Thereof,” incorporated in its entirety herein by reference and including the compound having the following formula (VI):

Peripheral opioid antagonists may also include polymer conjugates of opioid antagonists, as described in U.S. patent application Ser. No. 11/332,964, hereby incorporated by reference. Specific polymer conjugates include PEGylated naloxone and naltrexone.

Embodiments of the invention also encompass administration of more than one μ-opioid receptor, including combinations of μ-opioid receptor antagonists and combinations of mu and kappa antagonists, for example, a combination of methylnaltrexone and alvimopan.

The compounds employed in embodiments of the invention may exist in prodrug form. As used herein, “prodrug” is intended to include any covalently bonded carriers which release the active parent drug or compounds that are metabolized in vivo to an active drug or other compounds employed in embodiments of the invention in vivo when such prodrug is administered to a mammalian subject. Since prodrugs are known to enhance numerous desirable qualities of pharmaceuticals (e.g., solubility, bioavailability, manufacturing, etc.), the compounds employed in some embodiments of the invention may, if desired, be delivered in prodrug form. Thus, embodiments of the invention contemplate methods of delivering prodrugs. Prodrugs of the compounds employed in embodiments of the invention may be prepared by modifying functional groups present in the compound in such a way that the modifications are cleaved, either in routine manipulation or in vivo, to the parent compound.

Accordingly, prodrugs include, for example, compounds described herein in which a hydroxy, amino, or carboxy group is bonded to any group that, when the prodrug is administered to a mammalian subject, cleaves to form a free hydroxyl, free amino, or carboxylic acid, respectively. Other examples include, but are not limited to, acetate, formate, and benzoate derivatives of alcohol and amine functional groups; and alkyl, carbocyclic, aryl, and alkylaryl esters such as methyl, ethyl, propyl, iso-propyl, butyl, isobutyl, sec-butyl, tert-butyl, cyclopropyl, phenyl, benzyl, and phenethyl esters, and the like.

As noted, the compounds employed in embodiments of the invention may be prepared in a number of ways well known to those skilled in the art. All preparations disclosed in embodiments of the invention are contemplated to be practiced on any scale, including milligram, gram, multigram, kilogram, multikilogram, or commercial pharmaceutical scale.

As noted above for methylnaltrexone, compounds employed in embodiments of the invention may contain one or more asymmetrically-substituted carbon atoms, and may be isolated in optically active or racemic form. Thus, all chiral, diastereomeric, racemic form, epimeric form, and all geometric isomeric forms of a structure are intended, unless the specific stereochemistry or isomeric form is specifically indicated. It is well known in the art how to prepare and isolate such optically active forms. For example, mixtures of stereoisomers may be separated by standard techniques including, but not limited to, resolution of racemic form, normal, reverse-phase, and chiral chromatography, preferential salt formation, recrystallization, and the like, or by chiral synthesis either from chiral starting materials or by deliberate synthesis of target chiral centers.

Methods of embodiments of the invention, generally speaking, may be practiced using any mode of administration that is medically acceptable, e.g., any mode that produces effective levels of the active compounds without causing clinically unacceptable adverse effects. Such modes of administration include oral, rectal, topical (as by powder, ointment, drops, transdermal patch, or iontophoretic device), transdermal, sublingual, intramuscular, infusion, intravenous, pulmonary, intramuscular, intracavity, as an aerosol, aural (e.g., via eardrops), intranasal, inhalation, intraocular, or subcutaneous.

Additionally, the compounds in accordance with embodiments of the invention may be administered as an enterically coated tablet or capsule. In some embodiments, the μ-opioid receptor antagonist is administered by a slow infusion method or by a time-release or controlled-release method or as a lyophilized powder.

Further, the compounds in accordance with embodiments of the invention may be administered topically. Formulations for topical administration may include ointments, lotions, creams, gels, drops, suppositories, sprays, liquids and powders. Conventional pharmaceutical carriers, aqueous, powder or oily bases, thickeners and the like may be necessary or desirable.

When administered, the compounds of embodiments of the invention are given in pharmaceutically acceptable amounts and in pharmaceutically acceptable compositions or preparations. Such preparations may routinely contain salts, buffering agents, preservatives, and optionally other therapeutic ingredients.

When used in medicine, pharmaceutically acceptable salts of the compounds in accordance with embodiments of the invention may be used, but non-pharmaceutically acceptable salts may conveniently be used to prepare pharmaceutically acceptable salts thereof and are not excluded from the scope of the invention. Such pharmacologically and pharmaceutically acceptable salts include, but are not limited to, those prepared from the following acids: hydrochloric, hydrobromic, sulfuric, nitric, phosphoric, maleic, acetic, salicylic, p-toluenesulfonic, tartaric, citric, methanesulfonic, formic, succinic, naphthalene-2-sulfonic, pamoic, 3-hydroxy-2-naphthalenecarboxylic, and benzene sulfonic.

Buffering agents and preservatives may also be included in preparations in accordance with embodiments of the invention. Suitable buffering agents may include, but are not limited to, acetic acid and salts thereof (1-2% w/v); citric acid and salts thereof (1-3% w/v); boric acid and salts thereof (0.5-2.5% w/v); and phosphoric acid and salts thereof (0.8-2% w/v). Suitable preservatives may include, but are not limited to, benzalkonium chloride (0.003-0.03% w/v); chlorobutanol (0.3-0.9% w/v); parabens (0.01-0.25% w/v); and thimerosal (0.004-0.02% w/v).

For ease of administration, a pharmaceutical composition in accordance with embodiments of the invention may also contain one or more pharmaceutically acceptable excipients, such as lubricants, diluents, binders, carriers, and disintegrants. Other auxiliary agents may include, e.g., stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, coloring, flavoring, and/or aromatic active compounds.

A pharmaceutically acceptable carrier or excipient refers to a non-toxic solid, semi-solid or liquid filler, diluent, encapsulating material, or formulation auxiliary of any type. For example, suitable pharmaceutically acceptable carriers, diluents, solvents, or vehicles include, but are not limited to, water, salt (buffer) solutions, alcohols, gum arabic, mineral and vegetable oils, benzyl alcohols, polyethylene glycols, gelatin, carbohydrates such as lactose, amylose or starch, magnesium stearate, talc, silicic acid, viscous paraffin, vegetable oils, fatty acid monoglycerides and diglycerides, pentaerythritol fatty acid esters, hydroxyl methylcellulose, polyvinyl pyrrolidone, etc. Proper fluidity may be maintained, for example, by the use of coating materials such as lecithin or by the maintenance of the required particle size in the case of dispersions and by the use of surfactants. Prevention of the action of microorganisms may be ensured by the inclusion of various antimicrobial, e.g., antibacterial and antifungal, agents such as paraben, chlorobutanol, phenol, sorbic acid and the like.

If a pharmaceutically acceptable solid carrier is used, the dosage form of the compounds suitable for use in embodiments of the invention may be tablets, capsules, powders, suppositories, or lozenges. If a liquid carrier is used, soft gelatin capsules, transdermal patches, aerosol sprays, topical cream, syrups or liquid suspensions, emulsions, or solutions may be the dosage form.

For parenteral application, particularly suitable are injectable, sterile solutions, preferably nonaqueous or aqueous solutions, as well as dispersions, suspensions, emulsions, or implants, including suppositories. Ampoules are often convenient unit dosages. Injectable depot-form may also be suitable and may be made by forming microencapsule matrices of the drug in biodegradable polymers such as polylactide-polyglycolide, poly(orthoesters), and poly(anhydrides). Depending upon the ratio of drug to polymer and the nature of the particular polymer employed, the rate of drug release can be controlled.

For enteral application, particularly suitable are tablets, dragees, liquids, drops, suppositories, or capsules such as soft gelatin capsules. A syrup, elixir, or the like can be used wherein a sweetened vehicle is employed.

As noted, other pharmaceutical delivery systems may include time-release, delayed-release, or sustained-release delivery systems. Such systems can avoid repeated administrations of the compounds of the invention, increasing convenience to the patient and the physician and maintaining sustained plasma levels of compounds. Many types of controlled-release delivery systems are available and known to those of ordinary skill in the art.

For example, compounds of embodiments of the invention may be combined with pharmaceutically acceptable sustained-release matrices, such as biodegradable polymers, to form therapeutic compositions. A sustained-release matrix, as used herein, is a matrix made of materials, usually polymers, which are degradable by enzymatic or acid-base hydrolysis or by dissolution. Once inserted into the body, the matrix is acted upon by enzymes and body fluids. A sustained-release matrix may be desirably chosen from biocompatible materials such as liposomes; polymer-based system such as polylactides (polylactic acid), polyglycolide (polymer of glycolic acid), polylactide co-glycolide (copolymers of lactic acid and glycolic acid), polyanhydrides, poly(ortho)esters, polysaccharides, polyamino acids, hyaluronic acid, collagen, chondroitin sulfate, polynucleotides, polyvinyl propylene, polyvinyl pyrrolidone, and silicone; nonpolymer system such as carboxylic acids, fatty acids, phospholipids, amino acids, and lipids such as sterols; hydrogel release systems; silastic systems; peptide-based systems; implants and the like. Specific examples include, but are not limited to: (a) an erosional system in which the polysaccharide is contained in a form within a matrix, found in U.S. Pat. Nos. 4,452,775, 4,675,189, and 5,736,152 (herein incorporated by reference in their entireties), and (b) a diffusional system in which an active component permeates at a controlled rate from a polymer such as described in U.S. Pat. Nos. 3,854,480, 5,133,974, and 5,407,686 (herein incorporated by reference in their entireties). In addition, a pump-based hard-wired delivery system can be used, some of which are adapted for implantation. Suitable enteric coatings are described in PCT publication No. WO 98/25613 and U.S. Pat. No. 6,274,591, both incorporated herein by reference. Sustained- or controlled-release compositions may also be formulated as those wherein the active compound is protected with differentially degradable coatings, such as by microencapsulation, multiple coatings, etc.

Respecting methylnaltrexone specifically, aqueous formulations may include a chelating agent, a buffering agent, an anti-oxidant and, optionally, an isotonicity agent, preferably pH adjusted to between 3.0 and 3.5. Formulations that are stable to autoclaving and long term storage are described in U.S. patent application Ser. No. 10/821,811, published as 2004/0266806, entitled “Pharmaceutical Formulation,” the disclosure of which is incorporated herein by reference. Formulations of methylnaltrexone with increased shelf-life are also described in International Patent Publication No. WO 2008/19115, entitled “Formulations for Parenteral Delivery of Compounds and Uses Thereof,” hereby incorporated by reference. Lyophilized formulations of methylnaltrexone are described in U.S. patent application Ser. No. 11/899,724 and formulations comprising particles containing methylnaltrexone are described in U.S. Pat. No. 6,419,959, which is incorporated herein by reference. Formulations suitable for transdermal delivery of methylnaltrexone are described in International Patent Publication No. 2007/41544, hereby incorporated by reference.

Compounds in accordance with embodiments of the invention, mTOR inhibitors and μ-opioid receptor antagonists, are provided in combination in a synergistic antiproliferative and antimigratory effective amount. It will be understood, however, that the total dosage of the compounds and compositions of the invention will be decided by the attending physician within the scope of sound medical judgment. The specific therapeutically-effective dose level for any particular patient will depend upon a variety of factors including the disorder being treated and the severity of the disorder; activity of the specific compound employed; the specific composition employed; the age, body weight, general health, sex, and diet of the patient; the time of administration; the route of administration; the rate of excretion of the specific compound employed; the duration of the treatment; drugs used in combination or coincidental with the specific compound employed and like factors well known in the medical arts. For example, one technique is to start doses of the compound at levels lower than those required to achieve the desired therapeutic effect and to gradually increase the dosage until the desired effect is achieved.

If desired, an effective daily dose may be divided into multiple doses for purposes of administration. Consequently, single dose compositions may contain such amounts or submultiples thereof to make up a daily dose. As noted, those of ordinary skill in the art can readily optimize effective doses and co-administration regimens (as described herein) as determined by good medical practice and the clinical condition of the individual patient.

Generally, oral doses of the μ-opioid receptor antagonists, particularly peripheral antagonists, will range from about 0.01 to about 80 mg/kg body weight per day. It is expected that oral doses in the range from 1 to 20 mg/kg body weight will yield the desired results. Generally, parenteral administration, including intravenous and subcutaneous administration, will range from about 0.001 to 5 mg/kg body weight. It is expected that doses ranging from 0.05 to 0.5 mg/kg body weight will yield the desired results. Dosages may be adjusted appropriately to achieve desired drug levels, local or systemic, depending on the mode of administration. For example, it is expected that the dosage for oral administration of the μ-opioid receptor antagonists in an enterically coated formulation would be from 10 to 30% of the non-coated oral dose. In the event that the response in a patient is insufficient with such doses, even higher doses (or effectively higher than 30% dosage by a different, more localized delivery route) may be employed to the extent that the patient tolerance permits. Multiple doses per day are contemplated to achieve appropriate systemic levels of compounds. Appropriate system levels can be determined by, for example, measurement of the patient's plasma level of the drug using routine HPLC methods known to those skilled in the art.

In embodiments of the invention, an mTOR inhibitor compound may be administered as appropriate, e.g. in dosages which are known for compounds of embodiments of the invention, by any administration route, for example, enterally, (e.g., orally), or parenterally or topically. A variety of oral and parental dosage forms are known for the mTOR inhibitors. Oral daily dosages may range from 0.1 mg to 25 mg, in the form, e.g., of dispersible tablets. A weekly dosage may include up to 70 mg, depending on the disease being treated. For parental administration, including intravenous administration, an initial intravenous dosage will be between about 0.1 and 100 mg/m² when administered on a daily dosage regimen (daily for five days, every two to three weeks), and more suitably, between 0.1 and 1000 mg/m² when administered on a once weekly dosage regimen. For example, everolimus may be administered orally, in daily dosages from 0.1 mg up to 25 mg or 0.1 mg to 15 mg, including 0.1 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 2.5 mg, 5 mg, or 10 mg, e.g., in the form of dispersible tablets or in the form of a solid dispersion, depending on the disease being treated. Everolimus may be administered in a weekly dosage that may include up to 70 mg, such as 10 to 70 mg, or 30 to 50 mg, depending on the disease being treated. For further example, tacrolimus (Protopic) may be administered as an ointment of 0.03% to 0.1% (w/w) in an ointment base. Other mTOR inhibitors may be administered analogously, e.g. in similar dosage ranges.

In illustrated embodiments of the invention, the μ-opioid receptor antagonists are co-administered with an mTOR inhibitor. In other words, the co-administration of the μ-opioid receptor antagonist compound with an mTOR inhibitor, is suitably considered a pharmaceutical combination which contains an μ-opioid receptor antagonist and an mTOR inhibitor, the combination being adapted for the administration of the peripheral μ-opioid receptor antagonist on a daily or intermittent basis, and the administration of the mTOR inhibitor on a daily or intermittent basis. Thus, the μ-opioid receptor antagonists may be administered prior to, concomitant with, or after administration of the mTOR inhibitor. In an exemplary regimen, patients will receive a 30-minute intravenous infusion of the mTOR inhibitor, followed immediately or preceded by administration of the μ-opioid receptor antagonists. After one or more treatment cycles, the dosages can be adjusted upwards or downwards depending on the results obtained and any side effects observed. In an illustrated embodiment, particularly suitable is administration of the μ-opioid receptor antagonist prior to administration of the mTOR inhibitor.

Co-administrable agents in accordance with embodiments of the invention also may be formulated as an admixture, as, for example, in a single formulation or single tablet. These formulations may be parenteral or oral, such as the formulations described, e.g., in U.S. Pat. Nos. 6,277,384; 6,261,599; 5,958,452 and PCT Publication No. WO 98/25613, each hereby incorporated by reference.

Methods in accordance with embodiments of the invention can be used alone or in conjunction with other treatments to control the growth or migration of endothelial cells in connection with the various conditions described above. The mTOR inhibitor and the peripheral μ-opioid receptor antagonist may be co-administered with another therapeutic agent that is not an opioid or μ-opioid receptor antagonist or an mTOR inhibitor. Such suitable therapeutic agents include other anticancer agents.

Embodiments of the invention also include the treatment of cancer. The types of cancer that may be treated is limited only by the involvement of mTOR. Thus, it is contemplated that a wide variety of tumors may be treated using these therapies, including cancers of the brain, lung, liver, spleen, kidney, lymph node, pancreas, small intestine, blood cells, colon, stomach, breast, endometrium, prostate, testicle, ovary, skin, head and neck, esophagus, bone marrow, blood or other tissue.

In many contexts, it is not necessary that the tumor cell be killed or induced to undergo normal cell death or “apoptosis.” Rather, to accomplish a meaningful treatment, all that is required is that the tumor growth be slowed to some degree. It may be that the tumor growth is completely blocked, however, or that some tumor regression is achieved. Clinical terminology such as “remission” and “reduction of tumor” burden also are contemplated given their normal usage.

Embodiments of the invention are further explained by the following examples, which should not be construed by way of limiting the scope of the present invention.

EXAMPLES Example 1 Inhibition of VEGF-Induced Akt Activation

To assess the effects of methylnaltrexone (MNTX) on the VEGF-induced activation of the serine/threonine kinase Akt, a well-characterized endothelial cell line, human pulmonary microvascular endothelial cells (HPMVEC), was used. HPMVEC were serum starved for one hour and either untreated (control) or treated with VEGF (100 nM, 5 minutes) with or without pre-treatment (1 hour) with 100 nM MNTX, 100 ng/ml bevacizumab, 100 μM 5-FU, 100 nM MNTX+100 ng/ml bevacizumab or 100 nM MNTX+100 μM 5-FU. Cell lysates were obtained, run on SDS-PAGE and immunoblotted with anti-pSer⁴⁷³Akt, anti-pThr³⁰⁸Akt, anti-Akt or anti-actin antibody. The results indicated that methylnaltrexone abrogated VEGF-induced phosphorylation of Akt at the serine and threonine at positions 473 and 308, respectively (FIG. 2). Furthermore, methylnaltrexone in combination with bevacizumab and 5-FU synergistically inhibited Akt activation. The effects of various concentrations of MNTX (1.0, 10, 100, 1000 nM) on inhibition of VEGF-induced pSer⁴⁷³Akt (FIG. 3A) and pThr³⁰⁸Akt (FIG. 3B) immunoreactivity demonstrated that this inhibition is dose-dependent.

Cell Culture and Reagents—

Human pulmonary microvascular EC were obtained from Cambrex (Walkersville, Md.) and cultured as previously described (Singleton et al. (2006), Microvasc. Res. 72(1-2):3-11; Singleton et al. (2007), Am. J. Respir. Cell Mol. Biol. 37(2):222-231) in EBM-2 complete medium (Cambrex) at 37° C. in a humidified atmosphere of 5% CO₂, 95% air, with passages 6-10 used for experimentation. Unless otherwise specified, reagents were obtained from Sigma (St. Louis, Mo.). Vascular endothelial growth factor (VEGF) was purchased from R&D Systems (Minneapolis, Minn.). Methylnaltrexone bromide (MNTX) was purchased from Mallinckrodt Specialty Chemicals (Phillipsburg, N.J.). Bevacizumab was purchased from Genentech (South San Francisco, Calif.). 5-fluorouracil (5-FU) was purchased from Abraxis Pharmaceutical Products (Schaumburg, Ill.). Naltrexone and rapamycin were purchased from Sigma (St. Louis, Mo.). Reagents for SDS-PAGE electrophoresis were purchased from Bio-Rad (Richmond, Calif.) and Immobilon-P transfer membrane was purchased from Millipore (Millipore Corp., Bedford, Mass.). Rabbit anti-pSer⁴⁷³Akt, rabbit anti-pThr³⁰⁸Akt and rabbit anti-Akt antibodies were purchased from Cell Signaling Technologies (Danvers, Mass.). Mouse anti-β-actin antibody was purchased from Sigma (St. Louis, Mo.). Secondary horseradish peroxidase (HRP)-labeled antibodies were purchased from Amersham Biosciences (Piscataway, N.J.).

SDS-PAGE and Immunoblotting—

Cellular materials from treated or untreated HPMVEC were incubated with IP buffer (50 mM HEPES (pH 7.5), 150 mM NaCl, 20 mM MgCl₂, 1% Nonidet P-40 (NP-40), 0.4 mM Na₃VO₄, 40 mM NaF, 50 μM okadaic acid, 0.2 mM phenylmethylsulfonyl fluoride, 1:250 dilution of Calbiochem protease inhibitor mixture 3), subjected to SDS-PAGE in 4-15% polyacrylamide gels, transferred onto Immobilon™ membranes, and developed with specific primary and secondary antibodies. Visualization of immunoreactive bands was achieved using enhanced chemiluminescence (Amersham Biosciences). In order to investigate the relative amount of activated Akt, the pSer⁴⁷³Akt and pThr³⁰⁸Akt immunoreactive band intensities were divided by total Akt immunoreactive band intensity.

Example 2 Effect of Rapamycin on VEGF-Induced Endothelial Cell Migration and Proliferation

To investigate the role of mTOR in cellular migration and proliferation, the effect of rapamycin on HPMVEC migration and proliferation assays was determined. Human EC were assayed for VEGF (100 nM)-induced profileration (FIG. 4) and migration (FIG. 5) in the presence or absence of 0.01, 0.1, 1.0 or 10 nM rapamycin. The results demonstrate that inhibition of mTOR by rapamycin results in a dose-dependent inhibition of endothelial cell proliferation and migration. This is in agreement with previous studies demonstrating that mTOR is involved in these processes.

Human Pulmonary Microvascular EC Migration Assay—

Twenty-four transwell units with 8 μM pore size were used for monitoring in vitro cell migration. HPMVEC (˜1×10⁴ cells/well) were plated with various treatments to the upper chamber and VEGF (100 nM) was added to the lower chamber. Cells were allowed to migrate for 18 hours. Cells from the upper and lower chamber were quantitated using the CellTiter96™ MTS assay (Promega, San Luis Obispo, Calif.) and read at 492 nm. Percent migration was defined as the # of cells in the lower chamber divided by the number of cells in both the upper and lower chamber. Each assay was set up in triplicate, repeated at least five times and analyzed statistically by Student's t test (with statistical significance set at P<0.05).

Human Pulmonary Microvascular EC Proliferation Assay—

For measuring cell growth, HPMVEC [5×10³ cells/well] pretreated with various agents were incubated with 0.2 ml of serum-free media containing 100 nM VEGF for 24 h at 37° C. in 5% CO₂/95% air in 96-well culture plates. The in vitro cell proliferation assay was analyzed by measuring increases in cell number using the CellTiter96™ MTS assay (Promega, San Luis Obispo, Calif.) and read at 492 nm. Each assay was set up in triplicate, repeated at least five times and analyzed statistically by Student's t test (with statistical significance set at P<0.05).

Statistical Analysis—

Student's t test was used to compare the means of data from two or more different experimental groups. Results are expressed as means±S.E.

Example 3 Synergistic Effect of Methylnaltrexone and mTOR Inhibitors on VEGF-Induced Endothelial Cell Migration and Proliferation

Given the complex feedback inhibition signaling network that exists between Akt and mTOR, the migration and proliferation assays described above were used to determine whether the simultaneous inhibition of mTOR activation using rapamycin and inhibition of Akt using methylnaltrexone produced a synergistic effect on these processes. Human endothelial cells were assayed for VEGF (100 nM)-induced profileration (FIG. 6) and migration (FIG. 7) in the presence or absence of 10 or 100 nM MNTX, 10 nM naltrexone, 0.1 nM rapamycin, 100 nM MNTX+0.1 nM rapamycin or 10 nM naltrexone+0.1 nM rapamycin. Similar results were obtained with methylnaltrexone in combination with temsirolimus (FIG. 10).

The results demonstrate that methylnaltrexone and mTOR inhibitors synergistically inhibit the migration and proliferation of endothelial cells. Unlike the results observed for methylnaltrexone, treatment of human endothelial cells with temsirolimus did not inhibit VEGF-induced activation of Akt (FIG. 8). This indicates that the observed synergistic effect of methylnaltrexone in combination with mTOR inhibitors is likely due to inhibition of the mTOR signaling pathway at two distinct points, with methylnaltrexone-induced inhibition occurring upstream of Akt activation and inhibition by mTOR inhibitors occurring downstream of Akt activation (FIG. 12). This hypothesis is bolstered by the fact that methylnaltrexone inhibits VEGF-induced formation of mTOR Complex I and mTOR Complex II, while temsirolimus inhibits the formation of mTOR complex II only (FIG. 9A).

To further elucidate the mechanism of VEGF-induced Akt activation, human endothelial cells treated with VEGF with or without pretreatment with the PI3 kinase inhibitor, LY294002, Src siRNA or Rictor (mTOR complex II component) siRNA. Lysates were immunoblotted with anti-pSer⁴⁷³Akt, anti-pThr³⁰⁸Akt or anti-Akt antibody (FIG. 9B). PI3 kinase inhibitor inhibits VEGF-induced Akt threonine 308 phosphorylation. Inhibiting mTOR Complex 2 formation (Rictor siRNA) blocks VEGF-induced Akt serine 473 phosphorylation. Inhibiting Src expression (siRNA) blocks both Akt serine 473 and Akt threonine 308 phosphorylation. Further, the central role of tyrosine phosphatase (PTP) in the synergistic effect of methylnaltrexone in combination with mTOR inhibitors on human endothelial cell proliferation and migration was demonstrated using the potent PTP inhibitor 3,4-dephostatin, which inhibited these VEGF-induced pro-angiogenic events (FIG. 11).

MNTX and Temsirolimus Regulation of Akt Phosphorylation—

Human EC were serum starved for one hour and either untreated (control) or treated with VEGF (100 nM, 5 minutes) with or without pretreatment (1 hour) with 100 nM MNTX or 100 nM temsirolimus. EC lysates were obtained, run on SDS-PAGE and immunoblotted with anti-pSer⁴⁷³Akt, anti-pThr³⁰⁸Akt or anti-Akt antibody.

Analysis of mTOR Complex Formation and Regulation of Akt Phosphorylation—

Human EC were serum starved for one hour and either untreated (control) or treated with VEGF (100 nM, 5 minutes) with or without pretreatment (1 hour) with 100 nM MNTX or 100 nM Temsirolimus. EC lysates were obtained and immunoprecipitated with anti-Raptor (mTOR Complex 1 component) or anti-Rictor (mTOR complex 2 component) antibody. The immunoprecipitated material was run on SDS-PAGE and immunoblotted with either anti-mTOR, anti-FKBP12, anti-Raptor, anti-SIN1 or anti-Rictor antibody. To investigate the regulation of Akt phosphorylation, human EC were serum starved for one hour and either untreated (control) or treated with VEGF (100 nM, 5 minutes) with or without pretreatment with the PI3 kinase inhibitor, LY294002 (10 μM, 1 hour), Src siRNA or Rictor (mTOR complex 2 component) siRNA. EC lysates were obtained, run on SDS-PAGE and immunoblotted with anti-pSer⁴⁷³Akt, anti-pThr³⁰⁸Akt or anti-Akt antibody.

Synergistic Effects of MNTX with Temsirolimus on Inhibition of VEGF-Induced Human EC Proliferation and Migration.

Inhibition curves of human EC assayed for VEGF (100 nM)-induced proliferation and migration (24 hours) in the presence or absence of 0.1, 1.0, 10, 100 or 500 nM MNTX, Temsirolimus or 10 nM MNTX+Temsirolimus. MNTX inhibited EC VEGF-induced proliferation with an IC50 of ˜100 nM. Adding 10 nM MNTX to EC shifted the IC50 of Temsirolimus inhibition of VEGF-induced proliferation from ˜10 nM to ˜1 nM. Experiments were performed in triplicate. Error bars=standard deviation.

MNTX Synergy with Temsirolimus is Regulated by Tyrosine Phosphatase Activity.

Human EC were assayed for VEGF (100 nM)-induced proliferation and migration (24 hours) in the presence of 10 nM or 15 nM Temsirolimus (IC50 concentrations for inhibition of proliferation in the absence or presence of 3,4-Dephostatin, respectively) with or without 10 nM MNTX. Experiments were performed in triplicate. Error bars=standard deviation.

While not wishing to be limited by any particular theory, FIG. 12 depicts a possible mechanism for the synergy demonstrated by the results of the Examples.

Example 4 Treatment of Mammalian Subjects with mTOR Inhibitors in Combination with Methylnaltrexone

In a first set of experiments, mice are induced to develop tumors by transformation, inbreeding or transplantation of tumor cells. Forty-eight mice, each bearing tumors having a volume of at least 60 mm³, are randomly divided into four groups. The first group receives a control substance comprising neither an opioid antagonist nor an mTOR inhibitor. The second group receives the peripheral opioid antagonist methylnaltrexone administered via an acceptable route to contact the tumor with a therapeutically effective amount of methylnaltrexone, e.g., oral administration at a dose of 5 mg/kg/day. The third group receives the mTOR inhibitor, such as rapamycin, administered via an acceptable route to contact the tumor with a therapeutically effective amount of mTOR inhibitor, e.g., injection of rapamycin at a dose of 1 mg/kg/day. The forth group receives a combination of methylnaltrexone and mTOR inhibitor.

Differences in the rate of tumor growth, tumor size, angiogenesis within the tumor and mortality between each group of mice are recorded. Additional experiments will be performed using varied treatment doses of mTOR inhibitors, such as rapamycin, to determine the reduction in therapeutic dose of the mTOR inhibitor resulting from co-administration with methylnaltrexone.

Example 5 Treatment of Mammalian Subjects with mTOR Inhibitors in Combination with Alvimopan

In a first set of experiments, mice are induced to develop tumors by transformation, inbreeding or transplantation of tumor cells. Forty-eight mice, each bearing tumors having a volume of at least 60 mm³, are randomly divided into four groups. The first group receives a control substance comprising neither an opioid antagonist nor an mTOR inhibitor. The second group receives the peripheral opioid antagonist alvimopan administered via an acceptable route to contact the tumor with a therapeutically effective amount of alvimopan. The third group receives the mTOR inhibitor, such as rapamycin, administered via an acceptable route to contact the tumor with a therapeutically effective amount of mTOR inhibitor, e.g., injection at a dose of 1 mg/kg/day. The forth group receives a combination of alvimopan and mTOR inhibitor.

Differences in the rate of tumor growth, tumor size, angiogenesis within the tumor and mortality between each group of mice are recorded. Additional experiments will be performed using varied treatment doses of mTOR inhibitors, such as rapamycin, to determine the reduction in therapeutic dose of the mTOR inhibitor resulting from co-administration with alvimopan.

In summary, methods in accordance with embodiments of the invention are provided for treating a disease or disorder associated with proliferation and migration of cells, including cancer and other hyperproliferative diseases as well as autoimmune disease, which methods include co-administration of an mTOR inhibitor and a μ-opioid receptor antagonist.

The invention has now been described with reference to various specific embodiments and techniques. However, it should be understood that many variations and modifications may be made while remaining within the spirit and scope of the invention.

All publications, patents, and patent applications are herein expressly incorporated by reference to the same extent as if each individual publication, patent, or patent application was specifically and individually indicated by reference. In case of conflict between the present disclosure and the incorporated patents, publications and references, the present disclosure should control. 

The invention claimed is:
 1. A pharmaceutical combination comprising an mTOR inhibitor and a peripheral mu-opioid receptor antagonist in a pharmaceutically acceptable dosage form and in synergistically effective amounts to inhibit unwanted migration and/or proliferation of cells in a subject in need thereof with the proviso that the mTOR inhibitor is not FK506 and wherein the peripheral mu-opioid receptor antagonist is a compound of formula (II):

a single enantiomer, a mixture of enantiomers, a single diastereomer or a mixture of diastereomers thereof, or a pharmaceutically acceptable salt, solvate or prodrug thereof, wherein and X⁻ is chloride, bromide, iodide, carbonate or methylsulfate anion; and wherein the mTOR inhibitor is selected from the group consisting of TOP216, OSI-027, or a rapamycin derivative which is temsirolimus, everolimus, deforolimus, TAFA93, AP23573, ABT-578, or nab-rapamycin.
 2. The combination of claim 1, wherein the unwanted migration and/or proliferation of cells is agonist-induced.
 3. The combination of claim 1, wherein the mTOR inhibitor is temsirolimus.
 4. The combination of claim 3, wherein the peripheral mu-opioid antagonist is methylnaltrexone.
 5. The combination of claim 4 wherein, at the cells having unwanted proliferation and migration, the synergistically effective amount of temsirolimus is a concentration of ranging from 0.1 nM to 100 nM and a concentration of methylnaltrexone ranging from 0.1 to 100 nM. 